Originally published Fall Newsletter 2023. Written by Alexis Cardinali, PA-C.
Each year as the seasons change, outpatient clinics and emergency departments alike will see an influx of children with signs and symptoms of bronchiolitis starting in October, peaking in January/February, and ending in May. This is a major cause of hospitalization in infants and young children, so understanding risk factors, clinical presentation, and recommended management is essential for us all.
Most children will experience upper respiratory symptoms, followed by signs of lower respiratory tract infections (LRTIs) including wheezing and crackles. Patients typically present 3-5 days after illness onset, when symptoms tend to peak before gradually resolving. Evaluation should include an assessment of hydration, respiratory distress, and determination of whether there have been apneic episodes or periods of cyanosis or bradycardia. There is an increased risk for apnea in preterm compared to term infants.
Respiratory Syncytial Virus (RSV) is the most common cause of bronchiolitis in children under one, and a common cause of hospitalization and outpatient visits for children under two. Other causative viruses include rhinovirus, parainfluenza, human metapneumovirus, influenza, adenovirus, and coronavirus. Nasal swabs for respiratory viral panels or PCR testing can often successfully diagnose the underlying viral cause of bronchiolitis, however a clinical diagnosis is most common.1
Risk factors for severe disease include infants under six months old (especially if they are born during the first half of the RSV season), underlying chronic lung disease, infants born before 25 weeks old, congenital heart disease, secondhand smoke exposure, HIV-exposed infants, patients with Down syndrome, and immunocompromised patients. In addition, children under five with social vulnerability (lack of running water, young maternal age), asthma, low birth weight, anatomic defects of the airways, neurologic disease, crowded households, daycare, older siblings and high altitude are also at increased risk.2
Non-severe bronchiolitis can be managed at home with hydration maintenance, suctioning, and careful monitoring. Over the counter medications are not recommended, and there has been little quality evidence to recommend nebulized hypertonic saline. Patients can follow up in the office in 1-2 days, and a chest x-ray can be done if they do not improve as expected. Severe bronchiolitis is characterized as increased respiratory effort (tachypnea, nasal flaring, intercostal, subcostal or suprasternal retractions, accessory muscle use, grunting). Patients should be assessed at least every 15 minutes to look for these severe features. If they persist, the patient should be admitted for monitoring.3
Vaccinations including nirsevimab (Beyfortus) and palivizumab (Synagis) are recommended for infants and young children at risk for severe bronchiolitis. According to Centers for Disease Control and Prevention (CDC) guidelines, Beyfortus is recommended for infants younger than eight months born during or entering their first RSV season. If they are born 14 or more days after their mother got the RSV vaccine, they likely do not need to be vaccinated. Synagis is recommended in children less than 24 months of age who are at increased risk of severe disease (as described above). Synagis, unlike Beyfortus, must be given once a month during RSV season. Studies performed by the CDC suggest that Beyfortus reduces the risk of severe disease by 80%, and provides about 5 months of protection. Efficacy does likely wane as the season progresses.4
For pregnant mothers, The American College of Obstetricians and Gynecologists (ACOG) recommends the Pfizer RSV vaccine (Abrysvo) in women 32-36 weeks pregnant from September to January. This vaccine may lower the risk of severe RSV features in infants up to 6 months old.5
Bronchiolitis is a viral-induced lower respiratory tract infection driving many primary care and emergency department visits every year. In understanding common presentations, vaccine recommendations, and signs and symptoms of severe features of this condition, PAs can improve patient outcomes and continue to participate in preventative care for our patients.
1Piedra, Pedro. “Bronchiolitis in Infants and Children: Clinical Features and Diagnosis.” UpToDate, Wolters Kluwer, 16 Oct. 2023, www.uptodate.com/contents/respiratory-syncytial-virus-infection-clinical-features-and-diagnosis?search=pediatric+respiratory+virus&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H15.
2Barr, Frederick E, and Barney S Graham. “Respiratory Syncytial Virus Infection: Clinical Features and Diagnosis.” UpToDate, Wolters Kluwer, 22 May 2023, www.uptodate.com/contents/respiratory-syncytial-virus-infection-clinical-features-and-diagnosis?search=pediatric+respiratory+virus&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H15.
3Piedra, Pedro A, and Ann R Stark. “Bronchiolitis in Infants and Children: Treatment, Outcome, and Prevention.” UpToDate, Wolters Kluwer, 30 Aug. 2023, www.uptodate.com/contents/bronchiolitis-in-infants-and-children-treatment-outcome-and-prevention?search=pediatric+respiratory+virus.
4CDC. “RSV Vaccination: What Parents Should Know.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 28 Sept. 2023, www.cdc.gov/vaccines/vpd/rsv/public/child.html#:~:text=There%20are%20two%20RSV%20antibody,entering%20their%20first%20RSV%20season.
5ACOG. “Should I Get the RSV Vaccine during Pregnancy?” The American College of Obstetricians and Gynecologists, 1 Oct. 2023, www.acog.org/womens-health/experts-and-stories/ask-acog/should-i-get-the-rsv-vaccine-during-pregnancy#:~:text=ACOG%20recommends%20the%20Pfizer%20RSV,first%206%20months%20after%20birth.
Photo Credit: Photo by Annie Spratt on Unsplash.